Fostering Excellence

Medical schools and hospitals often spend huge sums of money purchasing and maintaining facilities and equipment, but relatively little time and effort attempting to understand the people who work with them. In fact, however, the single most expensive and certainly the most important item on the budget of many departments and physician practices is the compensation of the physicians themselves. The organizations alone do nothing. It is not the organizations but the people who work in them who make things happen. When something needs to get done, the crucial question to ask is not, "What lever should I pull?" but "Who can accomplish this?" In order to improve the quality of medical education we offer, we need to better understand the people who do the work.

We need to address some basic questions. Are excellent educators born or made? Why do some educators work harder and perform better than others? Can we predict which candidates for a faculty post will perform best? Are there steps that educational leaders can take to enhance the motivation of the people with whom we work? What motivators have the biggest effect? Which are more effective,"sticks" such as the threat of demotion and pay cuts, or "carrots" such as awards for teaching? Should we focus our efforts on placing our educational colleagues under tighter control, or should we attempt to increase their own sense of autonomy and empowerment?

If educational leaders do not understand the people we work with, the performance of our educational programs is likely to suffer. We will experience difficulties recruiting and retaining colleagues. Their performance will suffer, which not only threatens financial performance, but can adversely affect the quality of healthcare. The morale of everyone in the organization, including our own, may decline, because our needs and aspirations are not being taken into account in decision making. Failure to understand motivation compromises what the educational program can achieve.

One theory that beautifully contrasts different approaches to motivation is that of Douglas McGregor. He argues that there are two fundamentally different approaches to leadership, which flow from two very different views of human nature. One of these perspectives on human nature is generally negative, and the other positive. He calls these perspectives theory X and theory Y. Educational leaders who favor authoritarian approaches and prefer to work in organizations with a high degree of centralized control make the following theory X assumptions about people.

1. My colleagues dislike work and try to do as little of it as possible.

2. My colleagues will work only if they are provoked into it by direct control, coercion, and threats of punishment. Otherwise, they will show little commitment to the objectives of the educational program.

3. My colleagues have little ambition and would prefer to avoid as much responsibility as possible. Their principal concern is security.

As we would expect, educators and educational leaders operating from a theory X perspective tend to be highly directive, telling learners and colleagues exactly what they are supposed to do and extending to them little or no opportunity to participate in the decision-making process. When a learner asks,"Why do you want me to do that?" the response is likely to be simply, "Because I told you so." If a colleague objects, "I don't think that is very good idea," the supervisor might respond,"Well, I guess it is a good thing we don't pay you to think, isn't it?" Theory X leaders are not interested in building motivation or satisfaction, and helping learners achieve their aspirations is not a priority. Why? Because theory X leaders assume that we have no aspirations.

Theory X educators and educational leaders tend to regard others as tools. We are seen as useful as long as we are doing what we are told to do, but eminently expendable as soon as we fail to bend to the will of our supervisor. For a theory X leader to succeed in such tasks as recruitment and retention of learners and educators, it is necessary to dangle very large carrots or brandish a very big stick. Otherwise, people will sense that the leader really does not care about us, and would just as soon be rid of us, if there were some other way of getting the work done.

Theory Y contrasts with theory X in a number of important respects. According to McGregor, theory Y leaders regard work as as natural to us as play and rest. We are capable of finding in our work as learners or educators a great deal of personal fulfillment and often want to perform it for its own sake. External control and threats of punishment are not the only way to get us to do what is needed. When we are truly committed to what we are doing, we will display considerable self-direction. When the objectives of the educational program contribute to our own self-actualization, we tend to become very engaged in it.

McGregor rejects the view that we naturally shirk responsibility. Instead, he argues, we actively seek responsibility. When we seem inclined to shirk it, display little ambition, and seem concerned only with our own security, it is because our experience as educators and learners has taught us to, and not because we naturally see things that way. If we look carefully at our educational programs, we will discover that imagination and creativity are widely, not narrowly distributed, and much of the time, the intellectual abilities of the average educator and learner are only partially engaged. In short, most of us are capable of more than we are doing.

In contrast to the authoritarian theory X leader, the theory Y leader attempts to create work conditions that match the needs and aspirations of colleagues and learners. Where can each of us make a contribution for which we could be recognized? One of us might have strong information technology skills that could be put to work in developing and implementing new educational technologies. Another might be a good writer, and have a lot to offer in developing new educational materials. Still another might be a gifted classroom teacher, and perform best when working with learners in a face-to-face setting. A paramount objective is to involve colleagues and learners in decisions about how their work is targeted, organized, and evaluated, and to frame such decisions in terms of the larger strategy of the educational program.

Theory X represents a cynical view of human nature. It fosters an environment that health professionals, who place a premium on their own autonomy, are likely to find stifling. Theory Y,by contrast, holds that the most effective way to run an educational program is to respect and trust the people with whom we work.

Another helpful perspective on educational leadership is provided by David McClelland's "learned needs" theory. Applied to the educational context, it posits that each educator or learner operates with three fundamentally different sets of needs, which predominate to varying degrees in each of us. These needs are to some degree natural to us, but they are not merely inborn, and develop to varying degrees depending on our circumstances throughout life.

The first of these sets of needs is the need for achievement. Each of us wants to perform well in relation to recognized standards. We need to feel a sense of accomplishment, to help resolve problems, and to excel in our professional roles. The second is the need for power, the need of each of us to influence or control how others behave and to exercise authority over them. The third is the need for affiliation, our desire to be associated with others, to develop warm relationships with them, and to avoid conflict.

For many physicians, medical students, and residents, the need for achievement is strongest. Thus understanding and tending to this need is an important mission of any medical leader. People with a high need for achievement tend to prefer situations in which we can take personal responsibility for solving problems. If we find ourselves in situations with little or no influence over outcomes, we may become dissatisfied and lose motivation.

People with a high need for achievement also tend to set relatively high goals for ourselves. We are not trying to get away with doing as little as possible. We actually want to find projects that require us to exercise our abilities to the fullest. If our studies or work responsibilities do not provide us with such challenges, we are likely to grow bored, and perhaps to disengage. A lack of performance appraisal can be problematic for us, because we need systems in place that enable us to determine whether we are meeting our objectives.

The need for power should not be equated with a need to control people merely to be in charge. Viewed in its most positive light, the need for power manifests itself as a sincere commitment to the success of the organization, and not merely a subterfuge of using the organization as a springboard for our own success. We want the course or the organization to succeed, and we believe that our influence with others can help promote this objective. We genuinely want to have a beneficial effect with the organization and the people in it.

The need for power should be carefully attended to, particularly when developing and selecting leaders for an organization. If we ignore the need for power in those we educate and lead, it may foster the counterproductive attitude that they have no influence over others, which may leave them feeling useless and irrelevant. Such people will take their need for power elsewhere, in search of opportunities to play a more meaningful role.

The need for affiliation manifests as a desire to be identified with a group and to be well liked by its members. Those of us in whom the need for affiliation predominates tend to place a higher premium on the quality of our relationships than on our own accomplishments or authority. We may be willing to forego achievement and influence for the sake of friendship. This can cause problems in the realm of leadership, where we want so badly to be on good terms with everyone that we find it difficult to make the tough decisions that our organization requires.

What kinds of leadership challenges are likely to prove especially difficult for the educator with a high need for affiliation? These include enforcing discipline, punishing infractions against the rules, and terminating employees. We may find leadership responsibilities very difficult to bear, because leadership calls us to types of interactions that we are temperamentally inclined to avoid.

Similar problems can develop between the need for achievement and the need for power. Those of us with a high need for achievement may be among the most successful in an educational organization, but we do not necessarily provide the best leadership. We may, for example, tend to hoard responsibility, believing that we are the best qualified people to accomplish any task. This is problematic, however, because it means that the leadership abilities of others may be stunted, and because we tend to take on more than we can handle, working ourselves to death.

From an organizational point of view, it is vital that leadership responsibility be fairly widely distributed, so that we can draw upon the talents and experience of numerous people. High achievers tend to keep things to ourselves, but we need to do a better job of sharing if the educational program as a whole is going to thrive. In many situations, the individual with a high need for power may turn out to be the more effective leader, because we tend to think in terms of the entire group or organization, and to seek to lead others rather than do everything ourselves.

Victor Vroom has developed a theory of motivation grounded in what he terms expectancy. From the standpoint of expectancy theory, merely understanding what we need is not enough. We also need to understand the development of our expectations of how needs will be satisfied. He identifies three conditions that affect this decision-making process. First, we must believe that making an effort will change our desired level of performance. If we believe that it does not matter how hard we try, then we are unlikely to try harder. Second, we need to believe that improving our performance will help us achieve some goal that matters to us. Third, we need to value that goal.

From Vroom's point of view, we tend to view our daily work as more than an end in itself. We also see it as a means to other ends. He defines expectancy as our belief that effort will improve performance, and instrumentality as the belief that enhanced performance will enable us to achieve our goals. Hence, there are at least two levels of outcomes to which educational leaders must attend: levels of performance and levels of reward. The first level includes the quantity and quality of work we do, and the second includes the esteem of our colleagues, praise from learners and superiors, and promotions. We must believe that first-level outcomes contribute to second-level outcomes if we are to perform at our best.

Vroom also describes a factor he calls valence. Valence describes the value each of us ascribes to a particular outcome. One person might be relatively indifferent to salary, whereas to another, salary might be crucial. In the first case, salary has a low valence, and in the second, its valence is high. Thus, I could be certain that making a stronger effort would improve the quality of my work (expectancy = 1.0), and certain that this improved quality would increase my compensation (instrumentality = 1.0), yet care very little about earning a raise (valence = 0.1). Because the three factors are multiplicative, a low value assigned to any one leads to a lower overall level of motivation, and I would be unlikely to make a greater effort at work because I had been offered a bonus. If we wish to motivate ourselves, our learners, and our colleagues, educational leaders need to attend to all three of these factors.

A key mission of leaders is to determine what second-order outcomes would most motivate us. If our compensation package is our greatest motivator, then we must devise means of enabling our colleagues to increase their incomes by increasing the quantity or quality of work they do. Conversely, if we are motivated most by a desire to make a substantial contribution to the education of the next generation of physicians, then we must seek out ways to help our colleagues make such contributions. Only by understanding ourselves and the people we work with can we optimally facilitate our pursuit of excellence.

As McClelland reminds us, however, we need to recall that our aspirations are not set in stone and may change over time according to changes in culture. We need to attend not only to what we expect today, but to the development of our expectations in the future. In an academic department, it might be prudent to avoid making compensation the premier second-level outcome, for fear that attention will focus increasingly on lucrative activities to the detriment of academic missions such as teaching that generate less revenue. We need to determine as a culture where the maximization of income fits into our overall goals for ourselves and our organization.

Because each of us does not share identical views on the rewards of work, we need to maintain openness to diversity and flexibility in our leadership style. It could be disastrous to assume that the motivational perspectives of a vocal minority apply across the board to the much larger and perhaps silent majority.

There is no single, universally accepted theory of how to foster the pursuit of excellence. Each of us and the organizations in which we work is a highly complex entity, and any effort to reduce our hopes and aspirations into a handful of factors is bound to introduce some distortions. Yet this is no excuse for neglecting the subject. Leaders in medical education need to be technologically savvy, but we also need to be people wise.

Do our colleagues and learners have the opportunity to do what they need to do? Does the organization provide them the resources to get it done? How well do our policies and procedures mesh with the abilities and resources to enable each of us to excel? By understanding what makes people tick, we can do a better job of making our educational programs hum.